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psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis-transcription-errors
March 24, 2011 - Study
Preventing medication errors in community pharmacy: root-cause analysis of transcription errors.
Citation Text:
Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care. 2007;1…
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psnet.ahrq.gov/issue/patient-safety-event-reporting-large-radiology-department
March 04, 2015 - Commentary
Patient safety event reporting in a large radiology department.
Citation Text:
Schultz SR, Watson RE, Prescott SL, et al. Patient Safety Event Reporting in a Large Radiology Department. American Journal of Roentgenology. 2011;197(3). doi:10.2214/ajr.11.6718.
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psnet.ahrq.gov/issue/how-radiation-oncologists-would-disclose-errors-results-survey-radiation-oncologists-and
December 14, 2016 - Study
How radiation oncologists would disclose errors: results of a survey of radiation oncologists and trainees.
Citation Text:
Evans SB, Yu JB, Chagpar A. How radiation oncologists would disclose errors: results of a survey of radiation oncologists and trainees. Int J Radiat Oncol Bi…
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psnet.ahrq.gov/issue/lives-lost-lives-saved-updated-comparative-analysis-avoidable-deaths-hospitals-graded
July 09, 2019 - Book/Report
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Citation Text:
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group. Austin M, Derk J. Bal…
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psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation-medical-record
November 09, 2022 - Study
Agreement between patient-reported symptoms and their documentation in the medical record.
Citation Text:
Pakhomov S, Jacobsen SJ, Chute CG, et al. Agreement between patient-reported symptoms and their documentation in the medical record. Am J Manag Care. 2008;14(8):530-539.
C…
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psnet.ahrq.gov/issue/problem-5-whys
July 19, 2023 - Commentary
The problem with the '5 whys.'
Citation Text:
Card AJ. The problem with '5 whys'. BMJ Qual Saf. 2017;26(8):671-677. doi:10.1136/bmjqs-2016-005849.
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psnet.ahrq.gov/issue/medical-trainees-formal-and-informal-incident-reporting-across-five-hospital-academic-medical
May 10, 2016 - Study
Medical trainees' formal and informal incident reporting across a five-hospital academic medical center.
Citation Text:
Logio LS, Ramanujam R. Medical trainees' formal and informal incident reporting across a five-hospital academic medical center. Jt Comm J Qual Patient Saf. 2010;3…
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psnet.ahrq.gov/issue/patient-safety-north-america-beyond-operate-through-your-initials-and-sign-your-site
March 18, 2009 - Meeting/Conference Proceedings
Patient safety in North America: beyond "operate through your initials" and "sign your site."
Citation Text:
Wong DA, Lewis B, Herndon JH, et al. Patient Safety in North America: Beyond “Operate Through Your Initials” and “Sign Your Site”*. doi:10.2106/jb…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/recruitment-flyer-va.pdf
June 02, 2025 - RecruitmentFlyer_FAQs_VA
Frequently Asked Questions
1. Why should my practice participate in the Heart of Virginia Healthcare (HVH) initiative?
Your practice will receive personalized coaching on optimizing your practice model and culture; helping you
improve cardiovascular care for your patients. Improving func…
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psnet.ahrq.gov/issue/addressing-healthcare-associated-infections-and-antimicrobial-resistance-organizational
January 31, 2024 - Commentary
Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspective: progress and challenges.
Citation Text:
Murray E, Holmes A. Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspectiv…
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psnet.ahrq.gov/issue/computerized-physician-order-entry-helpful-or-harmful
January 06, 2018 - Commentary
Classic
Computerized physician order entry: helpful or harmful?
Citation Text:
Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11(2):100-3.
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psnet.ahrq.gov/issue/safe-use-cellular-telephones-hospitals-fundamental-principles-and-case-studies
August 04, 2021 - Commentary
Safe use of cellular telephones in hospitals: fundamental principles and case studies.
Citation Text:
Cohen T, Ellis WS, Morrissey JJ, et al. Safe use of cellular telephones in hospitals: fundamental principles and case studies. J Healthc Inf Manag. 2005;19(4):38-48.
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psnet.ahrq.gov/issue/human-factors-engineering-healthcare-systems-problem-human-error-and-accident-management
June 13, 2011 - Commentary
Human factors engineering in healthcare systems: the problem of human error and accident management.
Citation Text:
Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and accident management. Int J Med Inform. 2010;79(4):e1-17.…
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psnet.ahrq.gov/issue/disruptive-behaviors-among-physicians
August 14, 2014 - Commentary
Disruptive behaviors among physicians.
Citation Text:
Sanchez LT. Disruptive behaviors among physicians. JAMA. 2014;312(21):2209-2210. doi:10.1001/jama.2014.10218.
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psnet.ahrq.gov/issue/doctors-views-attitudes-towards-peer-medical-error
April 04, 2012 - Study
Doctors' views of attitudes towards peer medical error.
Citation Text:
Asghari F, Fotouhi A, Jafarian A. Doctors' views of attitudes towards peer medical error. Qual Saf Health Care. 2009;18(3):209-12. doi:10.1136/qshc.2007.025015.
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psnet.ahrq.gov/issue/patterns-nurse-physician-communication-and-agreement-plan-care
December 21, 2014 - Study
Patterns of nurse–physician communication and agreement on the plan of care.
Citation Text:
O'Leary KJ, Thompson JA, Landler MP, et al. Patterns of nurse-physician communication and agreement on the plan of care. Qual Saf Health Care. 2010;19(3):195-9. doi:10.1136/qshc.2008.03022…
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psnet.ahrq.gov/issue/full-disclosure-adverse-events-patients-and-families-icu-wouldnt-you-want-know
May 26, 2021 - Commentary
Full disclosure of adverse events to patients and families in the ICU: wouldn't you want to know?
Citation Text:
Doucette E, Fazio S, LaSalle V, et al. Full disclosure of adverse events to patients and families in the ICU: wouldn't you want to know? Dynamics. 2010;21(3):16-9. …
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psnet.ahrq.gov/issue/reframing-and-addressing-horizontal-violence-workplace-quality-improvement-concern
March 15, 2017 - Commentary
Reframing and addressing horizontal violence as a workplace quality improvement concern.
Citation Text:
Taylor RA, Taylor SS. Reframing and addressing horizontal violence as a workplace quality improvement concern. Nurs Forum. 2018;53(4):459-465. doi:10.1111/nuf.12273.
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psnet.ahrq.gov/issue/medication-safety-operating-room-literature-and-expert-based-recommendations
October 19, 2022 - Review
Medication safety in the operating room: literature and expert-based recommendations.
Citation Text:
Wahr JA, Abernathy JH, Lazarra EH, et al. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth. 2017;118(1):32-43. doi:10.1093/bja/aew…
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psnet.ahrq.gov/issue/care-transitions-and-home-health-care
August 25, 2011 - Review
Care transitions and home health care.
Citation Text:
Boling PA. Care transitions and home health care. Clin Geriatr Med. 2009;25(1):135-48, viii. doi:10.1016/j.cger.2008.11.005.
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